Among the limited supply of organs available for liver transplantation, a wide spectrum of quality exists. Some organs carry higher risks of disease transmission, and others carry higher risks of graft failure ranging from 20% to 40% at 3 years. Each time an organ offer is made, the patient and physician must decide whether to accept this offer, or wait for a better one to come along. Very little is known about how this decision is made. Although consensus recommendations suggest that higher risk organs should be given to patients with higher Model for End-stage Liver Disease (MELD) scores due to their risk of death while waiting, we recently published a study demonstrating that in current practice patients with lower MELD scores tend to receive the higher risk organs. Furthermore, significant variation exists between transplant centers in the use of high risk organs. Finally, although physicians are ethically and legally obligated to inform patients about the quality of organ they will receive, communicating the complex risk/benefit tradeoffs is difficult. The immediate goals of this proposal are to improve decision making about organ quality by 1) developing a model of transplant center organ quality utilization, 2) conducting a web-based survey of patients on the waiting list for liver transplantation to determine factors influencing acceptance of high risk organs, and 3) facilitating shared patient-physician decision making by developing and pilot testing a patient decision aid about organ quality. In order to conduct these studies, I will receive focused didactic coursework and mentoring in survey design and quantitative methodology, decision psychology and decision aids, and patient-oriented research and career development. My long-term goal is to become an independent clinical investigator and health services researcher in hepatology and liver transplantation, with a methodologic focus in decision sciences. The K23 award will provide me the protected time and advanced research training needed to achieve my goals and contribute to improved quality of care for patients with liver disease.